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Alameda County Emergency Food Distribution First-Time Customer Sign-In Survey [Template]
[Name of Contractor/Subcontractors]
Please complete only one survey per household one time. Do not complete survey if you have already done it before.
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Email
*
Your email
Name
(We will not share your name in connection with your survey responses. All survey responses will be combined and reported anonymously.)
Your answer
Zip code
*
Provide the zip code where you live.
Your answer
Phone number
*
(We will not share your phone # with your survey responses. This is only used to help you sign-in faster next time and for staff to contact you.)
Your answer
Email address
(We will not share your email address in connection with your survey responses. This is only used to let you know about food and food assistance resources in your area.)
Your answer
I am interested in receiving:
*
Groceries and fresh produce
Prepared meals
Both groceries/fresh produce and prepared meals
Total number of people in my household, including myself:
*
Choose
1
2
3
4
5
6
7+
Ages of all household members: In each row, select the number of people in each age group in your household.
*
0
1
2
3
4+
Ages 0-17
Ages 18-26
Ages 27-59
Ages 60+
0
1
2
3
4+
Ages 0-17
Ages 18-26
Ages 27-59
Ages 60+
Race/ethnicity of all household members: In each row, select the number of people in each group in your household.
*
0
1
2
3
4
5+
African-American/Black
Asian/Pacific Islander
Latina/Latino
Native American/American Indian
Mixed Race
White/Caucasian
Other: __________________________________
Decline to state
0
1
2
3
4
5+
African-American/Black
Asian/Pacific Islander
Latina/Latino
Native American/American Indian
Mixed Race
White/Caucasian
Other: __________________________________
Decline to state
One or more people in my household (check all that apply):
Is in quarantine due to being COVID-19-positive
Is in quarantine due to being exposed to a COVID-19 or suspected of being COVID-19-positive
Is medically vulnerable to COVID-19 (has heart condition, lung condition, immune-compromised (including cancer, HIV, etc.), diabetes, liver condition, kidney condition or on dialysis, pregnant, etc.)
Cares for or works with individuals who are medically vulnerable to COVID-19
One or more people in my household is experiencing (check all that apply):
Job loss due to COVID-19 (including due to childcare/care of household member needs)
Reduced hours or reduced income due to COVID-19 (including childcare/care of household member needs)
Homelessness
Recent or pending eviction from home
Unable to cook meals at home (due to lack of cooking facilities or disability requiring caregiver support with daily living)
One or more people in my household receives one or more of the following public benefits (check all that apply):
*
Unemployment Insurance Benefits
CalFresh
WIC (Women with Infants and Children) Nutrition
Free/reduced price school breakfast/lunch
SSI/SSDI/Disability
Medi-Cal
CalWORKs
General Assistance (GA)
Refugee Assistance
Work-Study or Cal Grant A/B College Financial Aid
I do not receive any benefits named above, but I believe I would qualify for one or more of these benefits due to low income
Other:
Required
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